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To help us meet your entire healthcare needs, please fill out this form completely in ink.If you have any questions or need assistance, please ask us and we will be happy to help.
Patient Information (Confidential)
Mr. / Mrs. / Miss Name ________________________________________________ Date ___________________
Soc. Sec. # _______________________________________________ Birth Date __________________________
Address _________________________________________________ City ________________________________
State ______________ Zip ____________ Home Phone _________________ Work Phone ___________________
Ok to Receive Correspondences via Text: Yes or N0 Cell Phone_____________________________________
Ok to Receive Correspondences via E-mail: Yes or N0 E-mail _________________________________________
Which phone number is best to contact you in the daytime if we have any questions __________________________
Previous Dentist ______________________Medical Physician _______________________ Phone# _____________
Pharmacy___________________ Emergency Contact ______________________________ Phone #_____________
Whom May We Thank for Referring You? ____________________________________________________________
Responsible Party
Name of Person for this Account ________________________________Relationship to Patient_________________
Address _____________________________________ Home Phone ___________ Drivers License # _____________
Soc. Sec. # ____________________ Birth Date ____________ Employer ___________________________________
Work Phone ________________ Is This Person Currently a Patient in our Office? Yes _________ No ____________
Insurance Information
Name of Insured ________________________________________ Relationship to patient _____________________
Birth Date __________________ Soc. Sec.# __________________________ Date Employed ___________________
Name of Employer _______________________________________________________________________________
Insurance Company _________________________________ Group # _____________ Policy/Id# _______________
Insurance Comp. Address _____________________________ City ______________ State _____ Zip ____________
Do You Have Any Additional Insurance? Yes _________ No _________ (If yes, please complete the following)
Name of Insured ________________________________________ Relationship to patient _____________________
Birth Date__________________ Soc. Sec.# __________________________ Date Employed __________________
Name of Employer _____________________________________________________________________________
Insurance Company _________________________________ Group # _____________ Policy/Id# _______________
Insurance Comp. Address _____________________________ City _______________ State _____ Zip ___________
Name Nickname Age Referred by How would you rate the condition of your mouth? Excellent Good Fair PoorPrevious Dentist How long have you been a patient? Months/YearsDate of most recent dental exam / / Date of most recent x-rays / / Date of most recent treatment (other than a cleaning) / / I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [____] 2. Have you had an unfavorable dental experience? 3. Have you ever had complications from past dental treatment? 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
7. Do your gums bleed or are they painful when brushing or flossing? 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? 9. Have you ever noticed an unpleasant taste or odor in your mouth? 10. Is there anyone with a history of periodontal disease in your family? 11. Have you ever experienced gum recession? 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
14. Have you had any cavities within the past 3 years? 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? 18. Do you have grooves or notches on your teeth near the gum line? 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? 20. Do you frequently get food caught between any teeth?
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? 25. Are your teeth becoming more crooked, crowded, or overlapped? 26. Are your teeth developing spaces or becoming more loose? 27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? 28. Do you place your tongue between your teeth or close your teeth against your tongue? 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? 30. Do you clench or grind your teeth together in the daytime or make them sore? 31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? 32. Do you wear or have you ever worn a bite appliance?
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? 34. Have you ever whitened (bleached) your teeth? 35. Have you felt uncomfortable or self conscious about the appearance of your teeth? 36. Have you been disappointed with the appearance of previous dental work? Patient’s Signature Date Doctor’s Signature Date
GUM AND BONE
BITE AND JAW JOINT
SMILE CHARACTERISTICS
PERSONAL HISTORY
TOOTH STRUCTURE
PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO
DENTAL HISTORY
To order, please visit: www.koiscenter.com © 2016 Kois Center, LLC
To order, please visit: www.koiscenter.com © 2016 Kois Center, LLC
MEDICAL HISTORY
DO YOU HAVE or HAVE YOU EVER HAD: YES NO1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridemetals (nickel, gold, silver, ____________)latexnuts fruit other
3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. orthopedic implant (joint replacement) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR > 3.5) 13. pneumonia, emphysema, shortness of breath, sarcoidosis 14. tuberculosis, measles, chicken pox 15. asthma 16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus) 17. kidney disease 18. liver disease 19. jaundice 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes (HbA1c = ) 24. stomach or duodenal ulcer 25. digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates) 27. arthritis 28. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)29. glaucoma 30. contact lenses 31. head or neck injuries 32. epilepsy, convulsions (seizures) 33. neurologic disorders (ADD/ADHD, prion disease) 34. viral infections and cold sores 35. any lumps or swelling in the mouth 36. hives, skin rash, hay fever 37. STI/STD/HPV 38. hepatitis (type ) 39. HIV/AIDS 40. tumor, abnormal growth 41. radiation therapy 42. chemotherapy, immunosuppressive medication 43. emotional difficulties 44. psychiatric treatment 45. antidepressant medication 46. alcohol/recreational drug use ARE YOU:47. presently being treated for any other illness 48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) 49. taking medication for weight management 50. taking dietary supplements 51. often exhausted or fatigued 52. experiencing frequent headaches 53. a smoker, smoked previously or use smokeless tobacco 54. considered a touchy/sensitive person 55. often unhappy or depressed 56. taking birth control pills 57. currently pregnant 58. diagnosed with a prostate disorder
Patient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient’s Signature Date
Doctor’s Signature Date
Drug Purpose
YES NO
ASA (1-6)
Drug Purpose
NOTICE OF PRIVACY PRACTICES(HIPAA Form)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USEDAND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLLY.
Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), all medical records and otheridentifiable health information of which we have knowledge must be kept confidential. All personal health informationused by us or disclosed by us is covered by this Act regardless of whether this personal health information is inelectronic, oral or paper form. Several new rights are granted to patients under this act, allowing control over how yourpersonal health information is used, how you can access it, and in some cases amend it.
We are required by law to maintain the privacy of your personal health information and to provide you with notice ofour legal duties and privacy practices with respect to your personal health information.
This Notice of Privacy Practices is effective on April 14, 2003.
We are bound to abide by the terms of this notice and reserve the right to make revisions to this policy. Shouldrevisions be made, you will be notified in writing, and a copy of the revised policy will be made available at yourrequest.
You will be asked to sign a consent form authorizing us to disclose your health information only for the followingpurposes, as defined under the Act:
❖ Treatment means the provision, coordination, or management of health care andrelated services by one or more healthcare provider with a third party;consultation between healthcare providers relating to a patient; or the referral of apatient for health care from one healthcare provider to another. An example ofthis would be a dentist referral to an orthodontist.
❖ Payment means obtaining reimbursement for the provision of health care:determinations of eligibility or coverage; billing; claim management; collectionactivities; justification of charges; and disclosure to consumer reporting agencies;protected health information relating to the collection for reimbursements (Onlycertain information may be disclosed). An example of this would be submittingyour bill for health care services to your insurance company.
❖ Health care operations are any activity related to cover functions in which weparticipate in the function of our offices, such as conducting quality assessmentsactivities; protocol development; case management and care coordination;auditing functions; business management and general administrative activities,including implementation of this regulation; customer service evaluations;resolution of grievances; fundraising; and marketing for which an authorization is
not required. An example of this would be evaluation customer service given topatients.
❖ Other disclosures and uses Public Health, Abuse and neglect, WorkersCompensation, Food and Drug Administration, Church Ministries, LawEnforcement, Judicial/Administrative proceedings and for SpecializedGovernmental Functions.
We may, without prior consent use or disclose your personal health information to carry out treatment, payment orhealth care operations:
❖ Directly to you at your request
❖ In an emergency treatment situation, if we attempt to obtain such consent as soon asreasonable practicable after the delivery of such treatment, if we are required by law totreat you and attempts to obtain consent are unsuccessful, or if we attempt to obtainconsent but are unable, due to barriers of communication, but we determine in ourprofessional opinion that treatment is clearly inferred from the circumstances.
❖ Pursuant to and in compliance with an authorization signed by you.
❖ Provided that you are informed in advance of the use and disclosure and have theopportunity to agree to or prohibit or restrict the use or disclosure. This may be an oralagreement between us and may include a directory maintained at our facility containingspecific information allowed by this Act.
All other uses and disclosers will be made only upon securing a written authorization form signed by you. You havethe right to revoke this authorization, at any time, upon written notice and we will abide by that request. However,exception would be any actions already taken, relying on your authorization, and prior to revocation notice.
We may contact you to provide appointment reminders or to inform you about treatment alternatives or other healthrelated benefits or services that may be of interest to you. We may also contact you for marketing purposes.
Under HIPAA, you have the following rights with respect to your protected health information:
❖ You have the right to request restrictions on certain uses and disclosures of protectedhealth information, including restrictions places upon disclosure to family members,close personal friends, or any other person you may identify. We are, however, notrequired to agree with a request restriction.
❖ You have the right to receive confidential communications of your protected healthinformation, either directly from us or from us by alternative means or from alternativelocations.
❖ You have the right to inspect and copy your protected health information.
❖ You have the right to amend protected health information, however, this request may bedenied under certain circumstances,
❖ You have the right to receive an accounting of disclosure of your protected healthinformation made by us in the six years prior to the date of the accounting request.
❖ You have the right to obtain a paper copy of this notice from us, even if you have alreadyagreed to receive the notice electronically.
If you feel your privacy rights or provisions of this notice of privacy have been violated, you have the right to file aformal written complaint. This complaint should be addressed either to the Privacy Officer at our office, or directly tothe Department of Health & Human Services, Office of Civil Rights. Both addresses appear below. You will not beretaliated against, in any way, for filing a complaint.
For more information about HIPAAOr to file a complaint, contact:
The U.S. Department of Health & Human Services OR Austin Creek DentalOffice of Civil Rights 4702 N Penngrove Way Ste. 1002201 6th Avenue, Room 900 Meridian, Idaho 83646Seattle, Washington 98121 [email protected]/ocr 208-938-18251-800-368-1019
ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES
(HIPAA Form)
YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT
I, ________________________________________, have received a copy of this office’s Noticeof Privacy Practices.
Please print Name of patient
Signature of Patient or Personal Representative Date
Description of Personal Representative’s Authority
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,but acknowledgement could not be obtained because:
❖ Individual refused to sign
❖ Communications barriers prohibited obtaining the acknowledgement
❖ An emergency situation prevented us from obtaining acknowledgement
❖ Other
Financial OptionsOur commitment is to provide quality dental care to the entire family through exceptional serviceand utilization of advanced technology.
Methods of Payment
1. Cash, Check or Credit Card (MasterCard, Visa)2. Dental Insurance (described below)
Dental Insurance
1. We are pleased you have dental insurance, and our office will assist you in obtaining the maximumbenefits specified in your contract. However, your insurance contract is between you, youremployer, and the insurance company. We will need you to bring us a copy of your benefitbooklet if you would like help interpreting your benefits.
2. As a courtesy to you, we will file your insurance and accept assignment of benefits if you havesigned the insurance payment authorization form. We ask that your estimated co-payment anddeductible be paid at the time of service.
3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily selectcertain services they will cover. We can not be liable for any misinformation given to us by yourinsurance company. Ultimately, any services not covered or reimbursed by your insurancecompany will become your responsibility for payment.
Related Information
1. Returned checks and Balances older than 60 days may be subject to additional collection fees andinterest charges of 1.5% per month, or 18% annually. These additional fees will be applied to theunpaid balance at the end of the month.
2. In the event that the account is not paid and we refer the account to collection, you will beresponsible for all the fees incurred for collection of your bill (i.e., attorney fees, court costs, andcollection agency fees).
3. Your appointment time has been reserved exclusively for you. Any change in your appointmentaffects many patients. 48 hours notice is needed to avoid a $50.00 charge.
I have read and understand the above information. I understand I am responsible (regardlessof my insurance) for any charges incurred from services rendered.
Name (Please print)___________________________________________________________________
Signature________________________________ Date ____________________
Consent for purpose of Treatment, Payments and HealthcareOperations (HIPAA Form)
I consent to the use or disclosure of my protected health information by Austin Creek Dental forthe purpose of diagnosing or providing treatment to me, obtaining payment for my health carebills or to conduct health care operations of Austin Creek Dental. I understand that diagnosis ortreatment of me by Austin Creek Dental may be conditioned upon my consent as evidenced bymy signature on this document.
I understand I have the right to request a restriction as to how my protected health information isused or disclosed to carry out treatment, payment or health care operations of the practice. AustinCreek Dental is not required to agree to the restrictions that I may request. However, if AustinCreek Dental agrees to a restriction that I request, the restriction is binding on Austin CreekDental and Tim Hansen DDS.
I have the right to revoke the consent, in writing, at any time, except to the extent that TimHansen DDS or Austin Creek Dental has taken action in reliance on this consent.
My “protected health information” means health information, including my demographicinformation, collected from me and created or received by my physician, another health careprovider, a health plan, my employer, or a health care clearinghouse. This protected healthinformation relates to my past, present or future physical or mental health or condition andidentifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review Austin Creek Dental’s Notice of Privacy Practices prior tosigning this document. The Austin Creek Dental’s Notice of Privacy Practices has been providedto me. The Notice of Privacy Practices describes the types of uses and disclosures of myprotected health care information that will occur in my treatment, payment of my bills or in theperformance of health care operations of Austin Creek Dental. The Notice of Privacy Practicesfor Austin Creek Dental is also provided on a bulletin located in the front office. This Notice ofPrivacy Practices also describes my rights and the Austin Creek Dental’s duties with respect to myprotected health information.
Austin Creek Dental reserves the Right to change the Privacy practices that are described in theNotice of Privacy Practices. I may obtain a revised notice of practices by calling the office andrequesting a revised copy be sent in the mail or asking for one at the time of my nextappointment.
_____________________________________________ ___________________Signature of Patient or Personal Representative Date
_____________________________________________Print Name of Patient or Personal Representative
_____________________________________________Description of Personal Representative’s Authority
HIPPA Form
Authorization to Transfer/Release Confidential Information
I, _________________________________________________________ authorize and request
Name of Dentist:Address:City: State: Zip:Phone: Fax:
To Release:(Please check all that apply)
___ All Current Radiographs ___ All Perio Charting ___ Full Dental Records(Including Pano / full mouth)
Regarding__________________________________________________________’s care to:Patient’s Name
Name: Austin Creek DentalAddress: 4702 N Penngrove Way, Suite 100City: Boise State: Idaho Zip: 83646Phone: 208-938-1825 Fax: 208-938-5763E-mail: [email protected]
I acknowledge that the data to be released may include material that is protected by Federal Law.My Signature below authorizes release of such information.
Signed: _________________________________________________ Date: _______________(Patient or Guardian)
___________________________________________________________________________Relationship to the Patient
